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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609076
Report Date: 05/29/2025
Date Signed: 05/29/2025 02:56:11 PM

Document Has Been Signed on 05/29/2025 02:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MELROSE VILLASFACILITY NUMBER:
197609076
ADMINISTRATOR/
DIRECTOR:		VERGARA, KANDICEFACILITY TYPE:
740
ADDRESS:823 N POINSETTIA PLACETELEPHONE:
(323) 746-7840
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 68CENSUS: 58DATE:
05/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Lori McKayTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 05/29/25, 10:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual visit. LPA met with Facility Administrator, Lori McKay, and reason for the visit was disclosed.

Facility is licensed as a two story residence, encompassing 34 shared resident bedrooms, each with bathroom; three (3) public bathrooms are located in hallway areas. Fire clearance approved for sixty-eight (68) non-ambulatory residents; of which, twenty (20) may be bedridden. Hospice waiver for twenty (20) residents.
At the time of this inspection, the facility occupied forty (40) ambulatory residents, and eighteen (18) non-ambulatory residents, six (6) of which are bedridden. Currently, four (4) residents are receiving hospice care services.

At 10:35 am, LPA conducted a tour of the physical plant with the Facility's Maintenance Director, Saul Aranda, and observed the following:

Facility’s main door is the primary access: Three (3) emergency exits are on the first floor, and two (2) emergency exits on the second floor. Exit routes are clear of obstruction. Screening area is located upon entrance. Delayed egress alarm sensors are present at all exit points and are working properly. Visitor sign-in sheet, hand sanitizer, gloves and masks are available. Room temperature is comfortable; wall thermostat displays a setting of 73 °F., within the required range. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 3/29/2025.

[Continued on LIC 809C]
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MELROSE VILLAS
FACILITY NUMBER: 197609076
VISIT DATE: 05/29/2025
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Fire Detection/Protection: Fire safety system is present in the facility. LPA observed multiple smoke and carbon monoxide alarms installed, hardwired, and interconnected. Fire system back up and tests are completed and documented on a biannual basis. Fire alarm system was tested and is working properly. Fire drill last conducted 3/29/2025. Fire extinguishers were observed on all floors of the Facility. All extinguishers were last serviced on 4/10/2025. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Facility stairwells contain a required evacuation chair.

Kitchen: LPA observed kitchen to be clean, with an adequate supply of perishable and non-perishable foods located in the refrigerator, freezer, and pantry. LPA observed a variety of fresh fruits, vegetables, meats, dry cereals, and desserts. Foods are properly labeled and stored. Knives and sharps are stored in a designated area of the kitchen. Kitchen is secured and inaccessible to residents.

Laundry: Is located on sub-floor level. Laundry room, soaps, and other cleaning agents are stored and inaccessible to residents. Linen storage observed to have adequate supply of linen and towels.

Commons: LPA observed upstairs and downstairs hallways, activity room, and dining room, finding them clean; furnishings observed to be in good condition. No obstructions, nor tripping hazards observed.


Due to time constraints, LPA was unable to complete this annual inspection visit. LPA will complete at a later date.

Exit interview conducted/Copy of report given to Administrator.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC809 (FAS) - (06/04)
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